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Medical Specializations


Urology => Infertility => Abortion


Abortion


INTRODUCTION
Abortion, termination of pregnancy before birth, resulting in, or accompanied by, the death of the fetus. Some abortions occur naturally because a fetus does not develop normally or because the mother has an injury or disorder that prevents her from carrying the pregnancy to term. This type of spontaneous abortion is commonly known as a miscarriage. Other abortions are induced-that is, intentionally brought on-because a pregnancy is unwanted or presents a risk to a woman's health.

Induced abortion, the focus of this article, has become one of the most intense and polarizing ethical and philosophical issues of the late 20th century. Modern medical techniques have made induced abortions simpler and less dangerous. But in the United States, the debate over abortion has led to legal battles in the courts, in the Congress of the United States, and state legislatures. It has spilled over into confrontations, which are sometimes violent, at clinics where abortions are performed. This article discusses the most common methods used to induce abortions, the social and ethical issues surrounding abortion, and the history of the regulation of abortion in the United States.

ABORTION METHODS
Induced abortions are performed using one of several methods. The safest and most appropriate method is determined by the age of the fetus, or the length of pregnancy, which is calculated from the beginning of the pregnant woman's last menstrual period (LMP). Most pregnancies last an average of 39 to 40 weeks. This period is divided into three stages known as trimesters. The first trimester consists of the first 13 weeks, the second trimester spans weeks 14 to 24, and the third trimester lasts from the 25th week to birth. Abortions in the first trimester of pregnancy are easier and safer to perform while abortions in the second and third trimesters require more complicated procedures and pose greater risks to a woman's health. In the United States, a pregnant woman's risk of death from a first-term abortion is less than 1 in 100,000. The risk increases by about 30 percent with each week of pregnancy after 12 weeks.

A variety of drug-based abortion methods may be carried out under a physician's supervision. In a method commonly referred to as the morning-after pill, a woman is given large doses of estrogen (a female hormone) within 72 hours of unprotected sexual intercourse and again 12 hours later. Depending on where a woman is in her menstrual cycle at the time she takes the estrogen, it will either inhibit or delay ovulation, or it may alter the uterine lining, preventing implantation of a fertilized egg. Typical side effects of the morning-after pill may include nausea, headache, dizziness, breast tenderness, and fluid retention.

Within the first seven weeks of pregnancy, a combination of two drugs can be given in pill form to abort a fetus. A pregnant woman first takes the drug mifepristone, known as RU-486, which blocks progesterone, a hormone needed to maintain the pregnancy. About 48 hours later, she takes another drug called misoprostol. Misoprostol is a prostaglandin (a hormone-like chemical produced by the body) that causes contractions of the uterus, the organ in which the fetus develops. These uterine contractions expel the fetus.

Misoprostol can also induce abortion when taken with methotrexate, an anticancer drug that interferes with cell division. A physician first injects a pregnant woman with methotrexate. About a week later, the woman takes misoprostol to induce uterine contractions and expel the fetus. Both of these drug combinations effectively end pregnancy in 95 percent of the women who take them. Some women experience nausea, cramping, and bleeding. The most serious complications, such as arrhythmia, edema, and pneumonia, affect the heart and lungs and may cause death.

In two procedures known as preemptive abortion and early uterine evacuation, a narrow tube called a cannula is inserted through the cervix (the opening to the uterus) into the uterus. The cannula is attached to a suction device, such as a syringe, and the contents of the uterus, including the fetus, are extracted. Preemptive abortion uses a smaller cannula and is performed in the first four to six weeks of pregnancy; early uterine evacuation, which uses a slightly larger cannula, is performed in the first six to eight weeks of pregnancy. Both types of abortions typically require no anesthesia and can be performed in a clinic or physician's office. The entire procedure lasts for only several minutes. In preemptive abortions the most common complication is infection. Women who undergo early uterine evacuation may experience heavy bleeding for the first few days after the procedure.

Vacuum aspiration is the procedure used for abortions in the 6th to 14th week of pregnancy. It requires that the cervix be dilated, or enlarged, so a cannula can be inserted into the uterus. Progressively larger, tapered instruments called dilators may be used to dilate the cervix. During the procedure, the cannula is attached to an electrically powered pump that removes the contents of the uterus. In some cases, the lining of the uterus must also be scraped with a spoonlike tool called a curette to loosen and remove tissue. This procedure is referred to as curettage. Vacuum aspiration may require local anesthesia and can be performed in a clinic or physician's office. Minor bruising or injuries to the cervix may occur when the cannula is inserted.

Dilation and curettage (D&C), performed during the 6th to 16th week of pregnancy, involves dilating the cervix and then scraping the uterine lining with a curette to remove the contents. A D&C often requires general anesthesia and must be performed in a clinic or hospital. Possible complications include a reaction to the anesthesia and cervical injuries. Since the development of vacuum aspiration, the use of D&C has declined.
After the first 16 weeks of pregnancy, abortion becomes more difficult. One method that can be used during this period is dilation and evacuation (D&E), which requires greater dilation of the cervix than other methods. It also requires the use of suction, a large curette, and a grasping tool called a forceps to remove the fetus. D&E is a complicated procedure because of the size of the fetus and the thinner walls of the uterus, which stretch to accommodate a growing fetus. Bleeding in the uterus often occurs. D&E must be performed under general anesthesia in a clinic or hospital. It is typically used in the first weeks of the second trimester but can be performed up to the 24th week of pregnancy.

An induction abortion can also be performed in the second trimester, usually between the 16th and 24th week of pregnancy. In this type of abortion a small amount of amniotic fluid, the fluid that surrounds the fetus, is withdrawn and replaced with another fluid. About 24 to 48 hours later, the uterus begins to contract and the fetus is expelled. When this method was first developed, physicians used a strong saline (salt) solution to abort the fetus; today they may also use solutions containing prostaglandins or pitocin, a synthetic form of a chemical produced by the pituitary gland that induces labor. Heavy bleeding, infection, and injuries to the cervix can occur. This procedure is performed in the hospital and requires a stay of one or more days.

Abortions at the end of the second trimester and during the third trimester require major surgery. Two such late-term procedures include hysterotomy and intact dilation and extraction. In hysterotomy, the uterus is cut open and the fetus is removed surgically in an operation similar to a cesarean section, but a hysterotomy requires a smaller incision. Hysterotomy is major abdominal surgery performed under general anesthesia.
Intact dilation and extraction, also referred to as a partial birth abortion, consists of partially removing the fetus from the uterus through the vaginal canal, feet first, and using suction to remove the brain and spinal fluid from the skull. The skull is then collapsed to allow complete removal of the fetus from the uterus.

SOCIAL AND ETHICAL ISSUES
As noted earlier, abortion has become one of the most widely debated ethical issues of our time. On one side are pro-choice supporters-individuals who favor a woman's reproductive rights, including the right to choose to have an abortion. On the other side are the pro-life advocates, who oppose abortion except in extreme circumstances, as when the mother's life would be threatened by carrying a pregnancy to term. At one end of this ethical spectrum are pro-choice defenders who believe the fetus is only a potential human being until it is viable. Until this time the fetus has no legal rights-the rights belong to the woman carrying the fetus, who can decide whether or not to bring the pregnancy to full term. At the other end of the spectrum are pro-life supporters who believe the fetus is a human being from the time of conception. As such, the fetus has the legal right to life from the moment the egg and sperm unite. Between these positions lies a continuum of ethical and political positions.

A variety of ethical arguments have been made on both sides of the abortion issue, but no consensus or compromise has ever been reached because, in the public policy debate, the most vocal pro-choice and pro-life champions have radically different views about the status of a fetus. Embryology, the study of fetal development, offers little insight about the fetus's status at the moment of conception, further confounding the issue for both sides. In addition, the point when a fetus becomes viable is constantly changing-with every passing year medical advances make it possible to keep a premature baby alive at an earlier stage. The current definition of viability is generally accepted at about 24 weeks gestation; a small percentage of babies born at about 22 weeks gestation have been kept alive with intensive medical care.
This combination of medical ambiguities and emotional political confrontations has led to considerable hostility in the abortion debate. For many people, however, the lines between pro-choice and pro-life are blurred and the issue is far less polarized. Many women who consider themselves pro-life supporters are concerned about possible threats to reproductive rights and the danger of allowing the government to decide what medical options are available to them. Similarly, many pro-choice individuals are deeply saddened by the act of abortion and seek to minimize its use through more education about, and use of, birth control.

Many people on all sides of the controversy feel the political debate has led to a stalemate because it ignores the nuances of the issue. In response, participants in the abortion debate find common ground in the admission that the issue is surrounded by complicated, difficult questions that require more than simplified pro-life or pro-choice rhetoric.

REGULATION OF ABORTION
Abortion has been practiced around the world since ancient times as a crude method of birth control. Although many religions forbade or restricted the practice, abortion was not considered illegal in most countries until the 19th century. There were laws during this time, however, that banned abortion after quickening-that is, the time that fetal movement can first be felt. In 1803 England banned all abortions, and this policy soon spread to Asia, Africa, and Latin America. Throughout the middle and late 1800s, many states in the United States enacted similar laws banning abortion. In the 20th century, however, many nations began to relax their laws against abortion. The former Union of Soviet Socialist Republics (USSR) legalized abortion in 1920, followed by Japan in 1948, and several Eastern European countries in the 1950s. In the 1960s and 1970s, much of Europe and Asia, along with Canada and the United States, legalized abortion.

An estimated 50 million abortions are performed worldwide each year. Of this number, a large percentage are performed illegally with disastrous consequences-illegal abortion accounts for an estimated 60,000 to 120,000 deaths worldwide each year, or about one in five pregnancy-related deaths. Illegal abortions are more likely to be performed by untrained people, in unsanitary conditions, or with unsafe surgical procedures or drugs. In some African countries, illegal abortion may contribute to up to 50 percent of pregnancy-related deaths. In Romania, where abortion was outlawed from 1966 to 1989, an estimated 86 percent of pregnancy-related deaths were caused by illegal abortion. In countries where abortion is legal, less than 1 percent of pregnancy-related deaths are caused by abortion.

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